running head: antisocial personality and substance use … mp... · 2017-02-10 · antisocial...

Running head: ANTISOCIAL PERSONALITY AND SUBSTANCE USE DISORDERS 1

An Adlerian Look at Antisocial Personality Disorder and Substance Use Disorder

A Master's Paper

Presented to

The Faculty of the Adler Graduate School

________________

In Partial Fulfillment of the Requirements for

the Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

________________

By:

Katie Tesmar

________________

Chair: Rashida Fisher

Member: Tamarah Gehlen

________________

September 2016

ANTISOCIAL PERSONALITY AND SUBSTANCE USE DISORDERS 2

Abstract

This project outlines Antisocial Personality Disorder from an Adlerian Perspective. It also

discussed the complications of Co-Occurring Substance use and explored the relationship

between chemical dependency and recidivism rates of criminal justice involvement. There was

significant research combining chemical dependency and personality disorders. There were also

several theories as to why people develop antisocial personality disorder which considers

whether environmental factors and genetic factors play a role in the disorder. This project

discussed an Adlerian overview exploring areas such as Social Interest, Inferiority feelings, and

Adler’s Unitary Theory.

Keywords: Antisocial Personality Disorder, Chemical Dependency, Adlerian Analysis,

Criminality


Acknowledgements

I would like to thank my family and friends for going through this long process of college

and grad school. It has been a long road, and they have done nothing but support me through

some of the hard times. I would also like to thank the supervisors I had had at my employment

agencies throughout the years and being able to work around some really weird scheduling

conflicts when it came to attending classes. I would not have made it through school if I also

couldn’t have worked at the same time.


Table of Contents

What is Antisocial Personality Disorder (ASPD)? ......................................................................... 5

The “Symptoms” of Antisocial Personality Disorder ................................................................. 6

The onset of Antisocial Personality Disorder ............................................................................. 7

Theories of Antisocial Personality Disorder ................................................................................... 9

Adlerian Analysis............................................................................................................................ 9

Goal of Superiority .................................................................................................................... 10

Feelings of Inferiority................................................................................................................ 10

Personality Development .......................................................................................................... 11

Social Interest ............................................................................................................................ 13

Criminality Associated with ASPD .............................................................................................. 14

Antisocial Personality in the Media .............................................................................................. 15

Comorbidity of Substance Use Disorders and Psychopathology ................................................. 17

Substance Use Disorders and Antisocial Personality Disorder ................................................. 17

Assessment and Differential Diagnosis Considerations ............................................................... 20

Adlerian Lifestyle Analysis ....................................................................................................... 22

Treatment Interventions ................................................................................................................ 24

Evidence-Based Practices ......................................................................................................... 24

Clinician’s Challenges Treating ASPD ..................................................................................... 26

Conclusion .................................................................................................................................... 27

Reflections .................................................................................................................................... 28

References ..................................................................................................................................... 29


An Adlerian Look at Antisocial Personality Disorder and Substance Use Disorder

There have been many studies done that show there is a high comorbidity rate between

Antisocial Personality Disorder (ASPD) and Substance Use Disorders (SUD). This project

explores the relationship between Antisocial Personality Disorder (ASPD) and Substance Use

and their influence on criminal justice system involvement. Specifically, this project examines

the co-occurring disorder of ASPD and substance use through the Adlerian concepts of Social

Interest, Inferiority, and Adler’s Unified Theory. The bearing on the treatment of substance

abuse is discussed. For treatment to be effective, the clinician should acknowledge the high

comorbidity of substance abuse in antisocial personality disordered individuals. For clinicians

who work with this population, the difficulty lies in that there is no specific evidenced-based

protocol that has been found to be effective with this diagnosis. The matter is further

complicated when there is substance use to complicate the presenting needs of the ASPD client

further.

What is Antisocial Personality Disorder (ASPD)?

There is a 1.0% prevalence of ASPD among adults in the United States (Lenzenweger,

Lane, Loranger, & Kessler, 2007), emotional and social indifference characterizes ASPD; in

which the affected person appears indifferent to social norms or the feelings of others (Rutter,

1997). ASPD can be evident when prison populations are often demonstrating individual

displays chronic behavior that manipulates, exploits or violates the rights of others and defined

antisocial behaviors.

The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric

Association, 2013; referred to as the DSM-V) described the essential feature of antisocial

personality disorder is “ a pervasive pattern of disregard for, and violation or, the rights of others


that begins in childhood or early adolescence and continues into adulthood” (American

Psychiatric Association, 2013, p. 659). Additionally, ASPD is characterized by (1) a lack of

regard for the moral or legal standards in the local culture, (2) gross disregard for societal rules,

and (3) marked diminished interpersonal relationship skills (American Psychiatric Association,

2013). Typically, the individual would have a need to have been diagnosed by age 18 and have a

history of Conduct Disorder diagnosed before age 15. People with ASPD sometimes have a

history of harming animals and having aggression towards other people, destroying property, and

tend to have an extensive criminal history (American Psychiatric Association, 2013). Although,

this is not true of the entire population of individuals with ASPD.

The “Symptoms” of Antisocial Personality Disorder

The symptoms of ASPD are representative of violating social norms and include an

enduring pattern of disregard for the rights of others (American Psychiatric Association, 2013).

There is a failure to conform to society's rules that often results in numerous arrests or legal

involvement as well as a history of deceitfulness where the individual attempts to “con people or

use trickery for personal profit.” Impulsiveness can present in persons diagnosed with ASPD

and includes angry outbursts, failure to consider consequences of behaviors, irritability, and/or

physical assaults (American Psychiatric Association , 2013). Finally, irresponsible behavior

often accompanies ASPD, as well as a lack of remorse for wrongdoings (Walker, 1996). These

previous statements regarding ASPD individuals being highly aggressive and manipulative can

only calculate for a portion of this population. There can be individuals with ASPD that blend

into society by not having irresponsible behavior and by calculating their actions in order not to

stick out. Some individuals with ASPD can have high popularity in society and sometimes seen

as highly successful.


This lack of social interest frequently leads to committing crimes ranging from small

misdemeanors to more violent crimes such as murder. Individuals with ASPD often lie, behave

violently or impulsively and have problems with drug and alcohol use. Because of these

characteristics, people with ASPD can have impaired functioning in the family, work, or school

responsibilities.

The Onset of Antisocial Personality Disorder

While antisocial personality disorder is a mental disorder diagnosed in adulthood, its

pattern begins in childhood. An early warning sign and key diagnostic feature of ASPD is a

history of childhood/adolescent behavior that meets the diagnostic criteria for Conduct Disorder

(CD) evident by the age of 15 (American Psychiatric Association, 2013). Black (2015)

recognized the link between adult ASPD and childhood misbehaviors. Black reported,

“Antisocial behaviors typically have their onset before age eight. Nearly 80% of people with

ASPD developed their first symptoms by age 11 years” (p. 309). It is hard to predict the

progression to ASPD in children with CD. However, research illustrates a positive correlation.

As of 2013, conduct disorder affected approximately 51.1 million people globally (Global

Burden of Disease Study, 2015); affecting 1-10% of children. Among youth in juvenile

detention facilities, rates of conduct disorder are between 23% and 87%. (U.S. Department of

Justice, 2016).

CD has two developmental courses; identified based on the age of onset of symptoms.

The first is known as the "childhood-onset type" which is assigned when the onset of symptoms

occurs before the age of 10 years. This course is linked to a more persistent life course and more

pervasive behaviors. Children in this group have greater levels of Attention Deficit

Hyperactivity Disorder (ADHD) symptoms, neuropsychological deficits, more academic


problems, increased family dysfunction, and a higher likelihood of aggression and violence

(Bressert. 2013). The second developmental course is “Adolescent-Onset type.” Children with

adolescent onset do not develop Conduct Disorder until after puberty, typically display less

aggressive behaviors, and have more ‘normal’ peer relationships. These adolescents are less

likely to have conduct disorder that persists into adulthood (Bressert. 2013). While the

diagnostic criteria for ASPD require a diagnosis of CD before age 15; the diagnostic features

support a stronger connection between Conduct Disorder-childhood onset type; particularly due

to the shared etiology.

It is believed that ASPD is likely the result of a combination of genetic and

environmental factors. Theories explaining the biological risk factors for ASPD include the

malfunction of certain genes, hormones, or parts of the brain. Some theories point to ASPD

being developed in individuals during their childhood years. Some life events could have

occurred such as, physical, sexual, or emotional abuse, neglect, and abandonment, or raised by a

parent who has an addiction or has ASPD as well. There is no true way to diagnose someone

with ASPD except when the individual is willing to share their lives with a mental health worker.

There has been researching that also supports people of minority cultures being wrongly

diagnosed due to language and cultural barriers (Dyden-Edwards, 2016), as well as the inability

of clinicians to understand various cultural contexts.

Conduct Disorder is generally diagnosed in early childhood years and can be

characterized from the American Psychiatric Association (2013) reports:

The essential feature of conduct disorder is a repetitive and persistent pattern of behavior

in which the basic rights of others or major age-appropriate societal norms or rules are

violated. These behaviors fall into four main groupings: aggressive conduct that causes


or threatens physical harm to other people or animals; non-aggressive conduct that causes

property loss or damage; deceitfulness or theft; and serious violations of rules.

Individuals with conduct disorder may also frequently commit grave violations of rules

(e.g., school, parental, workplace). Children with conduct disorder often have a pattern,

beginning before age 13 years, of staying out late at night despite parental prohibitions.

Children may also show a pattern of running away from home overnight (p. 472).

Diagnosing Conduct Disorder can be difficult to youth as it can be developmentally appropriate

to be defiant. If children have had trauma or other disruptions in their environment that may not

have been reported, they may be displaying appropriate anger and actions based on their reality

versus applying their behaviors to the standardized cultural norms. One must also consider the

implications of behavior and thinking that occur with substance use. Unfortunately, youth may

not be screened for environmental concerns or substance use, which could result in inaccurate

diagnosis (Swart & Apsche, 2014).

Theories of Antisocial Personality Disorder

Adlerian Analysis

Alfred Adler argued the individual was not a mere product determined by circumstances

but was an active determiner of his life. Every human being, except the ‘feeble-minded,' were

considered endowed with such creative power. Adler asserted people must be understood as

whole entities, indivisible from the social context of one’s family, culture, and history. The

individual creates a "style of living” reflective of their movements; directing all feeling, thought,

and action toward the goal of conquering the sense of inferiority or incompleteness (Ansbacher

& Ansbacher, 1964).


Goal of Superiority

Adler comprehended human life as upward movement, and from this notion, Adler

asserted the primary drive of humans is toward superiority. This striving is “innate in the sense

that it is part of life” (Ansbacher & Ansbacher, 1964, p. 104). One’s feeling of superiority,

perfection, or success is perceived and actualized in activities; not necessarily in dominance over

others. Adler argued (regarding mental health) superiority symbolized ability to meet and

overcome the demands of life.

Feelings of Inferiority

Adler primarily focused on an individual’s formative years in children and had many

theories about how inferiority can shape individuals as they move into adulthood. This

inferiority is context dependent and situationally determined- a value judgment by the individual

(Mosak & Maniacci, 1999). Inferiority feelings are the natural outcome and counterpart of the

striving. “In comparison with unattainable ideal perfection, the individual is continuously filled

with an inferiority feeling and motivated by it” (Ansbacher & Ansbacher, 1964, p. 117).

This is a reversal of Adler’s earlier view, in which he saw the striving as a compensatory

effort for primary inferiority feelings and which paralleled drive-reduction theory, which at best

does justice only to deficit motivation, not to growth motivation. The later reformulation

represents a great improvement in theory. If the individual incorporates constant feelings of

being judged as less than others around them, then the inferiority complex may become all-

consuming. A person with an inferiority complex tends to lack social interest and may be

focused on themselves and what they believe to be their deficiencies (Ashby & Kottman, 1996).


Ansbacher and Ansbacher (1964) stated:

Since the feeling of inferiority is regarded as a sign of weakness and as something

shameful, there is a strong tendency to conceal it. Indeed, the effort of concealment may

be so high that the person himself cease to be aware of his inferiority as such, being

wholly preoccupied with the consequences of the feeling and with all the objective details

that subserves its concealment. (p. 119)

Individuals with ASPD may not believe they are inferior. Those with ASPD can have

additional struggles with addiction, particularly in treatment, when there tends to be strong

directives given to seek and ask for help.

Personality Development

Individual psychology assumes a central personality dynamic reflecting the growth and

forward movement of life (Ansbacher & Ansbacher, 1964). Life is a future-oriented striving

toward an ideal, a goal of significance, of mastery, and of success. Adler (1914; as cited in

Ansbacher & Ansbacher, 1964, p. 96) stated, “we cannot think, feel, will or act without the

perception of some goal.” Children start their lives weaker and less socially skilled than the

adults around them. They have the desire to mature, to become a capable adult, and as they

gradually acquire skills and demonstrate their competence, they gain self-confidence and self-

reliance. This natural striving for perfection may, however, be held back if their self-image is

degraded by failures in physical, intellectual and social development or of they suffer from the

criticisms of parents, teachers, and peers (Mosak, & Maniacci, 1999). Adler (1914; as cited in

Adler, Liebenau & Stein, 2003) stated:

Every mental activity shows that its direction is governed by a predetermined goal.

However, soon after a child's psychological development starts, all these tentative,


individually recognizable goals, come under the dominance of the fictitious goal, a finale

that is regarded as firmly established. In other words, like a character drawn by a good

dramatist, the individual's inner life is guided by what occurs in the fifth act of the play.

This insight into any personality that can be derived from Individual Psychology leads us

to an important concept: If we are to understand the nature of an individual, then every

psychological manifestation should be perceived and understood as only preparatory for a

particular goal. Everyone develops a final goal, either consciously or unconsciously, but

ignorant of its meaning. (p. 28)

Griffith and Powers (2007) noted:

Adler framed what has been characterized as a unitary theory of mental illness. He

understood dysfunction, from neurosis to sociopathy to psychosis, as arising from faulty

training in childhood, resulting in the child’s erroneous evaluations of self, others, and the

world, and consequent mistaken movement asserting that all mistaken answer are degrees

of an infinite series of failures or abnormalities, or of the attempts of more or less

discouraged people to solve their life-problems without the use of cooperation or social

interest. (Griffith & Powers, 2007, p. 68)

Examining most popular people that have had ASPD or symptoms of ASPD, they suffered from

this unitary theory of mental illness. It may be impossible to live a life hurting other individuals

with no empathy for others and not have some psychosis or sociopathy.

Adler would say that these people suffered from not being included in society in some

way or another. Whether the person that suffered from ASPD came from a broken household or

their parents also suffered from a mental illness, Adler would say individuals with ASPD may

not have been given the right love and belonging that they deserved to have. There is no way to


know that if they were given the proper upbringing, and were a part of society if they would still

suffer from ASPD. Those with ASPD can have additional struggles with addiction, particularly

in treatment, when there tend to be strong directives given to seek and ask for help

Personality types. Adler identified four types of personality; distinguishable based on

one’s energy felt by others: (1) Ruling type, (2) leaning type, (3) Avoiding type, and (4) socially

useful type (Mosak & Maniacci, 1999). These 'types' are typically formed in childhood and are

expressions of the style of life. The ruling type, most closely aligned with ASPD, is

characterized by a tendency to be aggressive and dominant over others. Adler asserted that the

ruling type of personality possesses an overwhelmingly intense energy leading to avoidance by

others. The ruling type are perceived as bullies and highly manipulative. Notably, Adler

asserted that those with a ruling personality are likely to develop alcoholism or drug additions

(Mosak & Maniacci, 1999). The ruling type of personality strives for superiority and power and

are willing to manipulate situations and people to accomplish this goal.

The leaning type of personality is considered highly sensitive and use protective

behaviors to shield themselves. Equally, individuals with a leaning personality type depend on

others to help them move through life. The leading personality type is linked to psychoneurotic

symptoms: phobias, obsessions and compulsions, general anxiety, and hysteria (Mosak &

Maniacci, 1999). Low-risk taking and isolation characterize the avoiding personality type.

Lastly, the socially useful personality type are well received by others. Socially useful

personalities are very active and social and demonstrate social interest.

Social Interest

If Alfred Adler were alive today, he might say these individuals that suffer from ASPD

lack social interest. Social Interest is defined by Ansbacher and Ansbacher (1964) as, “to


understand what goes on in an individual, it is necessary to consider his attitude toward his

fellow men. The relationships of people to one another in part exist naturally and as such are

subject to change” (p. 127). A well-known example of someone with ASPD is Jeffrey Dahmer

who targeted the gay community due to his struggles with his sexuality. His social interest was

comprised due to his internalized homonegativity and was unable to connect and interact with

the world (Crime Museum, 2016b).

Yang, Chen, Xu, and Qian (2014) developed a study to see if individuals with personality

disorders have a higher level of self-control than the normalized public. They were able to

determine that individuals with less self-control tend to have more impulsive behaviors such as

compulsive spending, binge eating, aggressive behavior, and poor sexual restraint. They also

were able to demonstrate that those individuals with low self-control have a higher likelihood of

having symptoms of antisocial personality or having more significant criminal involvement.

The findings revealed a unique characteristic of self-control strength in people with ASPD. Only

the ASPD group exhibited significant depletion of self-control strength after an ego-depletion

task, not observed in the control group (Yang, Chen, Xu, & Qian, 2014). These findings would

lend support as to why Jeffrey Dahmer may have lacked social interest. If he felt that his ego

was depleted by being a gay man, he may have committed such crimes due to his lack of self-

control and lead to his superiority over others.

Criminality Associated with ASPD

A major proportion of our jail and prison population is made up of criminals with drug

offenses. Fazel and Danesh (2002) conducted a survey of offenders in the prison system and the

correlation of severe mental disorders. They were able to conclude that prisoners were more

likely to have major depression and symptoms of psychosis and ten more times likely to have


ASPD than most of the general population (Fazel & Danesh, 2002). Decision making is a

significant element of chemical dependency. Adler (1996) believed that individuals engaging in

criminal activity lacked social interest or a positive feeling towards their communities.

According to Adler (1996), feelings of inferiority are overcome by behaviors that enhance self-

esteem. He suggested that people develop fictional goals that are used to increase one’s sense of

pleasure and level of perceived power. This supports the correlations between ASPD and

criminal behavior. Further, Adler (1993) noted that individuals engaged in chronic criminal

behavior were attracted to a lifestyle that provides a feeling of euphoria and exhibit elevated self-

esteem and increased feelings of power, and thus receive ego gratification from perceived

elevated social status in the community.

When individuals are under the influence, they tend to make a lot of irrational decisions,

and this can lead them to get arrested due to the decisions they have been making. The human

brain’s capacity to utilize an executive functioning and exercise good decision making is

compromised by alcohol and drug use (Mellentin, Skot, Teasdale, & Habekost, 2013).

Mellentin, Skot, Teasdale, and Habekost (2013) reported: “Decision-making has become a

principal target or study in addiction research given that individuals with substance use disorder

(SUD) are characterized by a tendency to make choices that bring about immediate benefits” (p.

292). If there were different ways to intervene with individuals that have continued substance

abuse, the jail and prison system would not be as significant as it is now. Some offenders have

repeated their crimes sometimes and are appropriate for the prison system.

Antisocial Personality in the Media

As the presentation of ASPD can be so varied, it is difficult to pinpoint a consistent set of

behaviors. Some famous people have had either been diagnosed with ASPD or had


characteristics of the disorder. Charles Manson showed many signs of ASPD with the crimes

that he had carried out. He created a cult mainly of young women, whom he would brainwash to

perform his crimes after he gained their trust. He had a long murder spree of killing several

people with no remorse for his actions (Crime Museum, 2016a). Another well-known example

of someone with ASPD is Jeffrey Dahmer who targeted the gay community due to his struggles

with his sexuality. Due to his internalized homonegativity, his social interest was compromised

in how he was able to connect and interact with the world. It was reported that Dahmer felt

neglected and unloved by his family and was fascinated by fires, harming and kill animals, and

pathological lying. Dahmer did not show any remorse for the crimes that he committed which

also makes him suffering from signs of ASPD (Crime Museum, 2016b). While these are only

two examples, it is not the intention of this writer to imply that all persons with ASPD act

violently.

People that have committed violent crimes are not all subject to being diagnosed with

ASPD, but the percentage could be higher. On the other side, people that have ASPD are not

always considered to have committed any crimes at all, in fact, some people can live with ASPD

and not have any legal consequences. However, lots of research point to the high rates of

offenders in the prison system that have the co-occurring disorder but are living undiagnosed.

The reason they are living undiagnosed is that people with symptoms of ASPD may not want to

admit, or believe, that they have some of these symptoms. Because of the grandiose effects that

ASPD has on people, they may find that how they act and feel is the correct way to respond to

certain situations (Black. 2015).


Comorbidity of Substance Use Disorders and Psychopathology

Substance Use Disorders and Antisocial Personality Disorder

Robins (1998) stated, “There is no question but that Drug addiction is associated with

antisocial personality, and it is a precursor, conduct disorder, whether one looks at epidemiologic

or clinical data (p. 393).” The DSM-V states

The essential feature of a substance use disorder is a cluster or cognitive, behavioral, and

physiological symptoms indicating that the individual continues using the substance

despite significant substance-related problems. An important characteristic of substance

use disorders is an underlying change in brain circuits that may persist beyond

detoxification, particularly in individuals with severe disturbances. The behavioral

effects of these brain changes may be exhibited in the repeated relapses and intense drug

cravings when the individuals are exposed to drug-related stimuli. These persistent drug

effects may benefit from long-term approaches to treatment (American Psychiatric

Association, 2013, p. 483).

So how exactly does substance use disorder interact with antisocial personality disorder?

It is a co-occurring disorder. These two disorders can share similar qualities. Therefore, it is

hard to tell if one disorder causes the other. Robins (1998) stated:

The belief that both disorders require an early predisposition, probably of genetic origin,

implies that neither disorder can fully account for the other, but is consistent with either

disorder’s increasing the likelihood that the other disorder is expressed in a predisposed

person. The recklessness, impulsivity, and lawlessness that are symptoms of ASPD are

believed to increase exposure to substances by encouraging the seeking of new

experiences and disarming normal concerns about overuse. (p. 395)


Substance abuse is highly prevalent among individuals with a personality disorder

(Verheul, van den Bosch, & Ball, 2005). The two most common personality disorders associated

with substance use disorders are Antisocial Personality Disorder (ASPD). About 40% to 50% of

individuals with a substance use disorder meet the criteria for ASPD and approximately 90% of

individuals diagnosed with ASPD also have a co‐occurring substance use disorder (Messina,

Wish, & Nemes, 1999).

There continues to be a widely held belief that personality disorders in general and ASPD

in particular, are untreatable (Verheul & Herbrink, 2007). There is also a reluctance to work

with this population because of their difficult clinical management. Furthermore, individuals

with ASPD are often excluded from substance abuse treatment programs due to the symptoms of

their personality disorder. Likewise, persons with a substance use disorder are often excluded

from personality pathology treatment because they are often disruptive and uncooperative

(Messina et al., 1999).

The main characteristic of ASPD is a pervasive disregard for the rights of others. This

disorder begins in adolescence and continues into adulthood; the individual must be at least 18

years old to qualify for an ASPD diagnosis. ASPD is characterized by deceitful and manipulative

behavior. People with ASPD demonstrate impulsive and aggressive behavior, they have a low

tolerance for boredom, and they behave irresponsibly. Individuals with ASPD externalize their

difficulties; they attribute blame to others and do not want to face the consequences of their

actions, they lack empathy. These people are typically unable to sustain long‐term employment

or a monogamous relationship. Individuals with ASPD embrace a deviant lifestyle and often

commit criminal acts, which is demonstrated by their overrepresentation in the criminal justice

system (American Psychiatric Association, 2013). Substance abuse is highly prevalent in people


with personality disorders. Personality diagnoses range from 44% among those who abuse

alcohol to 79% among those who abuse opiates, with the most common Axis II diagnosis being

ASPD (Verheul et al., 2005).

Twin studies have indicated that there may be a genetic factor linking antisocial behavior

and substance use disorders (Krueger et. al., 2002). Consequently, the development of antisocial

behavior and substance dependence are traceable back to a common genetic factor. A similar

study by Krueger et al. (2002) examined a possible genetic factor in the development of these

disorders. Krueger et al. (2002) surveyed late adolescent twins. The results indicated that

substance dependence and antisocial behaviors commonly co-occurred and could be traced back

to externalizing factors, said to be highly heritable. Nonetheless, the externalizing factor did not

account for all of the patterns of co-occurring ASPD and Substance use. Overlapping diagnostic

criteria explains the high co‐occurrence of ASPD and substance use disorders (Verheul et al.,

2005).

Flory, Lynam, Milich, Leukefeld, and Clayton (2002) provide additional evidence for the

relationship between ASPD and substance use disorder. Flory et al. (2002) examined the

relationship between the Five-Factor Model (FFM) of personality to symptoms of alcohol and

marijuana abuse and internalizing psychopathology. Results of this qualitative study found a

positive correlation between personality characteristics and symptoms of alcohol abuse,

marijuana abuse, APD, and internalizing disorders. Specifically, Floy et al. (2002) found

symptoms of alcohol abuse correlated with high Extraversion and low Conscientiousness.

Additionally, low Extraversion and high Openness to Experience characterized those engaged in

marijuana abuse.


Trull, Waudby, and Sher (2004) assessed substance use disorder symptoms and

personality disorder symptoms. They found that personality symptoms from antisocial,

borderline, histrionic, and narcissistic personality disorders were significantly related to

substance use disorders. ASPD symptoms were significantly linked to substance use diagnoses.

Trull et al. (2004) concluded that Cluster B personality symptoms were significant predictors of

both alcohol and drug use diagnoses. Chávez, Dinsmore, and Hof (2010) found that ASPD had

the highest association with both alcohol use and drug use disorders. Compton, Conway,

Stinson, Colliver, and Grant (2005) established that individuals with ASPD had a 30.3% rate of

alcohol use disorders and a 10.3 % rate of other drug use disorders. Littlefield, Sher, and Wood

(2009) support a bidirectional relationship between ASPD and substance use disorders.

Littlefield et al. (2009) questioned the correlation between personality changes attributed to self-

correction on problem alcohol consumption. Littlefield, Sher, and Wood (2009) found

evidence that personality changes contribute to decreased problem alcohol use. Littlefield et al.

(2009) outlined a growth model indicating both normative and individual changes in alcohol use

occurring between ages 18 and 35 linked to changes in neuroticism and impulsivity.

Assessment and Differential Diagnosis Considerations

Diagnoses associated with antisocial personality disorder include substance‐related

disorders, attention‐deficit hyperactivity disorder (ADHD), and reading disorders. Research has

primarily focused on personality disorders, and their problematic clinical management (Verheul

et al., 2005). These symptoms can get in the way and overlap with each other so it can be hard to

know what symptoms are actually for which diagnosis, especially considering some individuals

have both diagnoses. While there are some differences in the presentation of symptoms between

ASPD and SUDs, there can also be a high correlation of similarities in presentation while under


the influence that can make detection of ASPD more difficult. Owens and Bergman (2009)

noted:

A large degree of overlap exists between developmental models of alcohol disorders and

antisocial personality disorder (APD). In particular, many disposition or biogenic models

describe a single or highly similar personality profile as being predisposed to both

alcoholism and antisocial behavior Alcohol use disorders and antisocial personality

disorder are also highly comorbid and appear to occur together reliably in families.

Antisocial personality disorder and substance problems in a biological parent are both

strong risk factors for their offspring to develop these negative behaviors, even if

adoptive families rear them. (p. 82)

Considering the research that has gone into finding out the differences between having ASPD

and just having challenging behavior, most of it suggests that it would need to be detected in

early life such as early teenage years. Newberry and Shukur (2012) reported “The Personality

Assessment Inventory (PAI) is a self-report measure of adult personality designed to “provide

information relevant to clinical diagnosis, treatment planning, and screening for

psychopathology” (p.586).

Although not designed specifically for use with offender populations, it possesses some

features that make it appealing to those who work in forensic and correctional settings. For

example, the PAI is shorter (344 items) than the Minnesota Multiphasic Personality Inventory–2,

which is the standard diagnostic instrument for measuring personality in forensic and

correctional settings. Also, the elements of the PAI are written at a grade lower than estimates

for comparable instruments, making it a suitable measure for use with offenders, many of whom


have limited reading ability. Furthermore, the PAI has non-overlapping scales for improved

discriminant validity (Newberry & Shukur, 2012).

Other things to consider when diagnosing an individual with ASPD is their gender.

Typically, men are seen to have more prominent symptoms and can present as more aggressive,

have more grandiose thoughts, and get into more legal trouble. This is not always the case

because women can be diagnosed with ASPD and not have such intense symptoms. Kries and

Cooke (2011) found that women might present as less aggressively either physically or mentally

than men present. Women tend to use more manipulation tactics such as sexual seduction and

relational aggression to achieve what they want from other individuals. Women also tend to

present more emotionally unstable whereas men tend to present more stable with their emotions.

(Kries & Cooke, 2011).

Adlerian lifestyle analysis: Adler’s personality types intended to exemplify

characteristic patterns directed under the individual's style of life (Mosak & Maniacci, 1999).

The lifestyle assessment is the primary psychological assessment tool of Adlerian Psychology

The assessment tool begins by exploring the individual's family constellation. The family

constellation includes family atmosphere and values; parental relationship; gender guiding lines;

and the challenge of adolescence. Next, the lifestyle assessment is the completion of the Early

Recollections, which consists of a collection of early memories. The assessment interpretations

include three summaries: (1) The Summary of the Family Constellation; (2) The Pattern of

Basic Convictions (derived from an interpretation of the early recollections); and (3) an

enumeration of the interfering ideas (Kern, Wheeler, & Curlette,1997).

Adler asserted that understanding one’s lifestyle facilitates greater insight into the

individual’s values. Worldview, and motivations for behaviors and actions. For people with


ASPD or a ruling personality type, the lifestyle assessment will uncover feelings of inferiority

and inadequacy due to a troubled childhood. Similarly, the lifestyle assessment will expose

goal-directed behavior motivated by a desire to feel superior and possess power and control

(Mosak & Maniacci, 1999). The Basic Adlerian Scales for Interpersonal Success—Adult

Inventory (BASIS- A) is an Adlerian personality measurement tool designed to detect the five

top areas of lifestyle: Belonging-Social Interest, Going Along, Taking Charge, Wanting

Recognition, and Being Cautious (Kern, Wheeler, & Curlette, 1997; Peluso, Peluso, Buckner,

Kern, & Curlette, 2009). The BASIS- An Inventory provides information on the individual’s

personality and their social interactions (Wheeler, Kern, & Curlette, 1993). Kern (1998)

summarizes the instrument’s five major thematic scales as follows. The Belonging Social

Interest (BSI) scale measures one’s level of social interest or community feeling. Persons scoring

high (i.e., above the 84th percentile) on this magnitude exhibit characteristics that are accepting,

cooperative, and empathetic in nature; reflected in the socially useful personality type. Those

scoring low (i.e., below the 16th percentile) on this scale may be discouraged and feel a sense of

alienation and/or loneliness. Those with ASPD would score in the lower percentile of BSI.

Kern (1998) noted the Going Along (GA) scale measures conformity versus

rebelliousness. People scoring high on this magnitude tend to be rule-focused, prefer structure,

and feel most comfortable with the routine. Those scoring low on this scale tend to be

argumentative, intolerant of routine, and act rebellious; reflective of the primary characteristics

of ASPD (Kern, Wheeler, & Curlette, 1997).

The Taking Charge (TC) scale measures leadership qualities. High scores on this scale

indicate controlling or domineering attributes; the person may have problems with others due to

their struggles for power and control. Those who score low on this scale do not feel the need to


assert themselves and tend to follow the lead of others (Kern, 1998). The individual with ASPD

would score high on the tc measures (Kern, Wheeler, & Curlette, 1997)

The Wanting Recognition (WR) scale measures a person’s level of need for approval and

sensitivity to social situations. High scorers on the Wanting Recognition scale seek approval

from others. Also, these individuals tend to be success-oriented and achievement-focused. Those

scoring low on this scale do not feel the need for approval of others (Kern, 1998).

The Being Cautious (BC) scale measures uncertainty within the family of origin and its

effects upon self-worth. Respondents scoring high on the Being Cautious scale exhibit lifestyle

attributes that may be 1) overly careful and mistrusting, 2) impulsive and perceived by others as

less responsible, or 3) a combination of 1 and 2. Individuals scoring low on this scale may be

viewed as trusting, flexible, and accepting. Also, low scorers are socially skilled and can deal

with ambiguity and complex life events (Kern, 1998). The BASIS-A is found to be equivalent to

the findings of the Minnesota Multiphasic Personality Inventory- II (MMPI-II) in detecting

personality disorders (Kern, Wheeler, & Curlette, 1997; Wheeler, Kern, & Curlette, 1993).

Treatment Interventions

Evidence-Based Practices

Reid and Gacono (2000) have suggested different treatment interventions for ASPD,

including correctional settings, individual therapy, group therapy, cognitive therapy, behavioral

therapy innovative programs, and medications. Reid and Gacono (2000) found that the most

efficient are innovative programs; that take the client out of their usual environment and into and

hidden area using negative reinforcement measures. These interventions occur in nature and are

sometimes told to work as a team on rugged terrain or navigate a desert.


Since this paper focuses on the co-occurring substance use disorders and ASPD, it is

asserted that treating the substance use will also help with the ASPD symptoms. Hatchett (2015)

stated, “well-designed treatment studies have provided convincing evidence that clients with

comorbid ASPD can benefit from substance abuse treatment, thus providing strong evidence for

treatment efficacy. There is also a significant body of research to support the clinical utility of

substance abuse interventions for clients with comorbid ASPD” (p. 22). It is parallel to treating

conduct disorder before it gets to be a full diagnosis of ASPD.

Clark, Vanyukov, and Cornelius (2002) state, “A causal model explaining the association

between childhood antisocial behaviors and the development of alcohol use disorders during

adolescence, if it can be validated, has implications for prevention, evaluation, and treatment of

those behaviors” (p. 113). Weisz (2014) highlighted doubt on prospects for preventing or treating

antisocial behavior. Further noting family-based research suggested that behavioral

interventions to build parenting skill might reduce child conduct problems, and multiple parent

training programs were developed and shown to be effective. Later evidence showed that even

seriously delinquent adolescents could be turned around through intensive multisystem

interventions, although the high cost of such interventions limits their availability, and they are

often introduced after arrests have been made, and considerable harm is done to youths, families,

and society.

If there were ways to incorporate such interventions that aren’t as costly, then the

individual could maybe have a chance not fully to develop ASPD. However, what has been

stated earlier in this paper is that this disorder does not fully have to do with the environment as

some of it is also related to the way the brain has developed. Moody, Franck and Bickel (2016)

noted:


Individuals with multiple psychopathologies have deficits in planning for the future,

beyond that used in drug seeking behaviors. Increased disregarding in combined

substance and psychopathology profiles suggest a greater chance of treatment failure and

consequently may necessitate individualized treatment using adjunctive interventions to

achieve better treatment outcomes. (p. 196).

Clinician’s Challenges Treating ASPD

Who treats these individuals? Duggan (2009) reports, “Mental health professionals have

always been ambivalent in their response to treating and managing those with a personality

disorder, and this especially applies to those with ASPD. Even forensic practitioners, who might

be expected to be more sympathetic, are often antagonistic, viewing therapeutic interventions for

this group as no more than sanctioning exploitative and rule-breaking behavior (p. 219). The

counselor that is working with individuals that have ASPD must have qualities such as patience

and understanding as they can be tough to work with. Particularly with the disruptive behavior

that can show the person should also have good boundaries and able to hold other accountable

for their actions.

There is no saying if the individual will be able to move through their lives without

having some of the ASPD factors get in their way. Black (2015) notes:

While chronic and lifelong for most people with ASPD; the disorder tends to improve

with advancing age. Earlier onset is associated with a poorer prognosis. Other

moderating factors include marriage, employment, early incarceration (or adjudication

during childhood), and degree of socialization. (p. 12)


Conclusion

Antisocial Personality Disorder and substance use disorders understood from an Adlerian

point of view, suggests individuals experience feelings of inferiority and work toward achieving

superiority, power and control. The individual’s engagement in criminal activity demonstrates a

lack social interest. This is why these individuals can make up quite a bit of the population that

ends up in the prison system. Given that the BASIS-A Inventory uses a unique method of recall

of childhood experiences rather than measuring present functioning, it may become a very useful

tool to assess for criminality in a subtle and non-threatening manner (Kern, Wheeler, & Curlette,

1997; Wheeler, Kern, & Curlette, 1993).

Nonetheless, not all individuals that have symptoms of ASPD result in criminal activity.

Some people are still living normal lives but may have a hard time connecting with other people

in society as they have a lack of remorse for others and their feelings. They may have a hard

time keeping a permanent job and may not live what is considered a normal life. There is still

some research that could be done to understand a deeper connection of ASPD and how people

are subject to this specific personality disorder. With the research that is out there, it still is an

unanswered question because it can be a mixture of the environment they grow up in and their

genetic makeup. It is common that individuals with ASPD either grew up in a broken home with

alcoholic parents or they grew up as misbehaved children, which is where the Conduct Disorder

could come into place and as children, could be diagnosed with this disorder. For clinicians, it is

important to make sure all the questions are being covered when diagnosing for ASPD.

Given the nuanced nature of ASPD and substane use disorder cultural considerations are

vital to proper assessemnt, diagnosis, and treatemtn intervetions. Using the BASIS –A can

support a more comprehensive assessment of ASPD that goes beyond symptomology to the


guiding values and beliefs influencing behavior. Troubled adolescents and adults who display

the “W” profile may be counseled using Adlerian techniques to help them identify guiding ideals

and core alues as way to help them effect change and lead more productive lives in greater

cooperation with others in regards to treating the individual with ASPD, it goes back and

catching the symptoms in early childhood. The research thoroughly backs up that if it is caught

at early childhood, the individual will have a greater chance at not developing ASPD. However,

sometimes no matter where the individual grew up, if they are unwilling to accept treatment then

they simply cannot change their position with the diagnosis.

Reflections

Reflecting upon my experience with presenting my project at the North American Society

for Adlerian Psychology (NASAP) 2016 conference, I am glad that I took the initiative to push

myself out of my comfort zone. It was fascinating to see all the other projects that others were

presenting and to see the interest some others had in the project that I was presenting. I met

many people that had some interesting stories to tell about their experience working with

individuals with ASPD and how difficult it can be to help them. I enjoyed how laid back the

conference was and that I was able to converse with many different people in a more casual

setting, but it still pushed me out of my comfort zone.


References

Adler, P. (1993). Wheeling and dealing: An ethnography of an upper-level drug dealing and

smuggling community. New York, NY: Columbia University Press.

Adler, A. (1996). The structure of neurosis. Individual Psychology: The Journal of Adlerian

Theory, Research & Practice, 52(4), 351.

Adler, A., Liebenau, G. L. (Trans.), & Stein, H. T. (Ed.). (2003). Journal articles, 1914-1920:

Expanding the horizons of child guidance, neurosis & psychosis. Bellingham, WA:

Classical Adlerian Translation Project, Alfred Adler Institute of Northwestern

Washington.

Ansbacher, H. L., & Ansbacher, R. R. (Eds.). (1964). The Individual Psychology of Alfred Adler.

New York, NY: Harper & Row.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, D.C.: Author.

Ashby, J. S., & Kottman, T. (1996). Inferiority as a distinction between normal and neurotic

perfectionism. Individual Psychology: The Journal of Adlerian Theory, Research &

Practice, 52(3), 237.

Black, D. W. (2015). The natural history of antisocial personality disorder. Canadian Journal of

Psychiatry, 60(7), 309-314.

Bressert, S. (2013). Conduct disorder symptoms. Psych Central. Retrieved from

http://psychcentral.com/disorders/conduct-disorder-symptoms/

Chávez, J. X., Dinsmore, J. A., & Hof, D. D. (2010). Assessing the incidence rates of substance

use disorders among those with antisocial and borderline personality disorders in rural


settings. International Journal of Psychology: A Biopsychosocial Approach, 2010(6),

57-66.

Clark, D. B., Vanyukov, M., & Cornelius, J., (2002). Childhood antisocial behavior and

adolescent alcohol use disorders. Alcohol Research & Health, 26(2), 109-115.

Compton, W. M., Conway, K. P., Stinson, F. S., Colliver, J. D., & Grant, B. F. (2005).

Prevalence, correlates, and comorbidity of DSM-IV antisocial personality syndromes and

alcohol and specific drug use disorders in the United States: Results from the National

Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical

Psychiatry, 66(6), 677-685. doi:10.4088/JCP.v66n0602

Crime Museum. (2016a). Charles Manson and the Manson family. Retrieved from:

http://www.crimemuseum.org/crime-library/charles-manson-and-the-manson-family/

Crime Museum. (2016b). Jeffrey Dahmer. Retrieved from http://www.crimemuseum.org/crime-

library/jeffrey-dahmer/

Dryden-Edwards, R. (2016). Antisocial personality disorder treatment and tests. Retrieved from

http://www.medicinenet.com/antisocial_personality_disorder/article.htm

Duggan, C. (2009). A treatment guideline for people with antisocial personality disorder:

Overcoming attitudinal barriers and evidential limitations. Criminal Behaviour & Mental

Health, 19(4), 219-223. doi:10.1002/cbm.726

Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23000 prisoners: A systematic review

of 62 surveys. Lancet, 359(9306), 545-550.

Flory, K., Lynam, D., Milich, R., Leukefeld, C., & Clayton, R. (2002). The relations among

personality, symptoms of alcohol and marijuana abuse, and symptoms of comorbid


psychopathology: Results from a community sample. Experimental and Clinical

Psychopharmacology, 10(4), 425-434.

Global Burden of Disease Study. (2015). Global, regional, and national incidence, prevalence,

and years lived with disability for 301 acute and chronic diseases and injuries in 188

countries, 1990-2013: A systematic analysis for the global burden of disease study 2013.

Lancet, 386(9995), 743-800. doi:10.1016/S0140-6736(15)60692-4. PMID 26063472

Griffith, J., & Powers, R. L. (2007). The lexicon of Adlerian psychology: 106 terms associated

with the individual psychology of Alfred Adler. Port Townsend, WA: Adlerian

Psychology Associates,.

Hatchett, G. T. (2015). Treatment guidelines for clients with antisocial personality disorder.

Journal of Mental Health Counseling, 37(1), 15-27.\

Kern, R. (1998). BASIS-A interpretive key and guide for clinicians. Highlands, NC: TRT

Associates, Inc.

Kern, R., Wheeler, M., & Curlette, W. (1997). BASIS-A inventory interpretive manual.

Highlands, NC: TRT Associates, Inc.

Kreis, M. F., & Cooke, D. J. (2011). Capturing the psychopathic female: A prototypicality

analysis of the comprehensive assessment of psychopathic personality (CAPP) across

gender. Behavioral Sciences & the Law, 29(5), 634-648. doi:10.1002/bsl.1003

Krueger, R. F., Hicks, B. M., Patrick, C. J., Carlson, S. R., Iacono, W. G., & McGue, M. (2002).

Etiologic connections among substance dependence, antisocial behavior, and personality:

modeling the externalizing spectrum. Journal of Abnormal Psychology, 111, 411‐424.

https://en.wikipedia.org/wiki/Digital_object_identifier

https://en.wikipedia.org/wiki/PubMed_Identifier

https://www.ncbi.nlm.nih.gov/pubmed/26063472


Lenzenweger, M. F., Lane, M. C., Loranger, A.W., & Kessler, R. C. (2007). DSM-IV personality

disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6),

553-564

Littlefield, A. K., Sher, K. J., & Wood, P. K. (2009). Is “maturing out” of problematic alcohol

involvement related to personality change? Journal of Abnormal Psychology, 118(2),

360–374. http://doi.org/10.1037/a0015125

Mellentin, A. I., Skøt, L., Teasdale, T. W., & Habekost, T. (2013). Conscious knowledge

influences decision-making differently in substance abusers with and without co-morbid

antisocial personality disorder. Scandinavian Journal of Psychology, 54(4), 292-299

Messina, N., Wish, E., & Nemes, S. (1999). Therapeutic community treatment for substance

abusers with antisocial personality disorder. Journal of Substance Abuse Treatment, 17,

121‐128

Moody, L., Franck, C., & Bickel, W. K. (2016). Full length article: Comorbid depression,

antisocial personality, and substance dependence: Relationship with delay discounting.

Drug and Alcohol Dependence, 160, 190-196. doi:10.1016/j.drugalcdep.2016.01.009

Mosak, H. H., & Maniacci, M. (1999). A primer of Adlerian psychology. New York, NY:

Brunner- Routledge.

Newberry, M., & Shuker, R. (2012). Personality assessment inventory (PAI) profiles of

offenders and their relationship to institutional misconduct and risk of reconviction.

Journal of Personality Assessment, 94(6), 586-592. doi:0.1080/00223891.2012.669220

Owens, M. R., & Bergman, A. (2009). Alcohol use and antisocial behavior in late adolescence:

Characteristics of a sample attending a GED program." Journal of Child & Adolescent

Substance Abuse, 19(1), 78-98.


Peluso, P. R., Peluso, J. P., Buckner, J. P., Kern, R. M. & Curlette, W. (2009). Measuring

lifestyle and attachment: An empirical investigation linking Individual Psychology and

attachment theory. Journal of Counseling & Development, 87, 394–403.

doi:10.1002/j.1556-6678.2009.tb00123.x

Reid, W. H., & Gacono, C. (2000). Treatment of antisocial personality, psychopathy, and other

characterologic antisocial syndromes. Behavioral Sciences & the Law, 18(5), 647-662.

Robins, L. N. (1998). The intimate connection between antisocial personality and substance

abuse. Social Psychiatry & Psychiatric Epidemiology, 33(8), 393-399.

Swart, J., & Apsche, J. (2014). A comparative treatment efficacy study of conventional therapy

and mode deactivation therapy (MDT) for adolescents with conduct disorders, mixed

personality disorders, and experiences of childhood trauma. International Journal of

Behavioral Consultation and Therapy, 9(1), 23-29. doi:10.1037/h0101011

Trull, T. J., Waudby, C. J., & Sher, K. J. (2004). Alcohol, tobacco, and drug use disorders and

personality disorder symptoms. Experimental and Clinical Psychopharmacology, 12, 65‐

75.

U.S. Department of Justice. (2016). Psychiatric disorders of youth in detention (NCJ 210331).

Retrieved from https://csgjusticecenter.org/youth/.../juvenile-justice-bulletin-psychiatric-

disorders-in-y

Verheul, R., van den Bosch, L. M. C., & Ball, S. A. (2005). Substance abuse. In J. M. Oldham,

A. E. Skodol, &; D. S. Bender (Eds.), Textbook of personality disorders (pp. 463-475).

Washington, DC: American Psychiatric Publishing.


Verheul, R., & Herbrink, M. (2007). The efficacy of various modalities of psychotherapy for

personality disorders: A systematic review of the evidence and clinical recommendations.

International Review of Psychiatry, 19, 25‐38

Walker, S. I. (1996). A dose of sanity: Mind, medicine, and misdiagnosis. Hoboken, NJ:

John Wiley & Sons Inc.

Weisz, J. R. (2014). Short-term treatment as long-term prevention: Can early intervention

produce legacy effects?. The American Journal of Psychiatry, 171(6), 600-602.

doi:10.1176/appi.ajp.2014.14030361

Wheeler, M., Kern, R., & Curlette, W. (1993). BASIS-A inventory. Highlands, NC: TRT

Associates, Inc.

Yang, Y., Chen, F., Xu, K., & Qian, M. (2014). Self-control strength in prison inmates with

antisocial personality disorder. Journal of Forensic Psychiatry & Psychology, 25(5), 613-

622. doi:10.1080/14789949.2014.933859

running head: antisocial personality and substance use … mp... · 2017-02-10 · antisocial...

Documents